In an interaction with ARCHANA JYOTI, a team of doctors from AIIMS Delhi’s Department of Surgical Disciplines led by HoD Dr (Prof.) Sunil Chumber gives a comprehensive medical reference information including symptoms, diagnoses, treatments, and follow-up of gallstones disease that impacts up to 10% of the population in the country. Unchecked dietary habits, sedentary lifestyles, and the rising prevalence of obesity and metabolic syndrome are confirmed risk factors.  Here we present the first part of the article.

Gallbladder stones, also known as gallstones, are hardened deposits of digestive fluid that form in your gallbladder, a small organ located under the liver that stores bile, a digestive fluid produced by the liver.

These stones are typically made of cholesterol, bilirubin, and calcium salts and can range in size from tiny grains to several centimetres in diameter.

The gallstones disease (GD) can manifest in various forms, from asymptomatic gallstones to acute cholecystitis, a severe inflammation of the gallbladder.

"The incidence of GD in India is on rise, with estimates suggesting that it affects up to 10% of the Indian population. Poor dietary habits, increased sedentary lifestyles, and the rising prevalence of obesity and metabolic syndrome are to be blamed," says Dr Piyush Ranjan

"There is disproportionately higher incidence in north India compared to the south. Gallstone disease is more common in women than in men, with a female-to-male ratio of 2:1. It also tends to affect people over the age of 40, although it can occur in younger individuals as well."

If left untreated, GD can have significant health consequences, such as acute cholecystitis, obstructive jaundice, and pancreatitis which cause recurrent episodes of pain in the abdomen and may be severe enough requiring hospitalisation, adds Dr Prasanna Ramana

Hence, early diagnosis and management are crucial to prevent complications and improve outcomes.  A simple Ultrasound scan of the abdomen is more than sufficient to diagnose gallstone disease, Mostly gallstones are asymptomatic or incidental gallstones, informs Dr Yshwant Singh  Rathore.

“Asymptomatic Gallstones are stones in gallbladder which cause no symptoms or complications and are diagnosed during routine ultrasound incidentally for other abdominal conditions.

“Classically, pain due to gallstones is felt in the right upper quadrant or epigastrium, and may radiate to the back or the right shoulder. Atypical presentations include dyspepsia , postprandial discomfort, constipation, bloating, nausea and vomiting. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications and about 80% of gall stone cases are asymptomatic.”

Thankfully, gallstones can be detected easily due to easy availability and use of diagnostic ultrasound for a wide range of abdominal complaints as well as routine check-ups, he says.

“Patient with cholelithiasis may develop complications like acute cholecystitis (which may evolve into empyema, progress to gallbladder perforation or even gangrene of the gallbladder, cholangitis (due to common bile duct calculi) and pancreatitis. It has been observed that in most cases of gall bladder cancers, gallstones are associated. In India, gallbladder cancer is the commonest GI cancer in women, points out Dr Ravi Chandra.

Dr Devender Singh and Dr Jyoti Sharma enlists these complications:

Complications of Gallstones: Around 20% of people with gallstones may develop one or more complications in their lifetime. These may have a wide array of symptoms, ranging from moderate abdominal pain to symptoms requiring surgery.

Biliary colic: This may present as a severe pain in the right upper or central abdomen that may last from 30 minutes to several hours. The pain may radiate to the back or tip of the right shoulder. It may occur after a fatty meal and may be associated with nausea.

Cholecystitis: This refers to the inflammation of gallbladder which may present as severe pain in the right upper and central abdomen, radiating to back or right shoulder and is usually associated with nausea, vomiting or fever. There is tenderness in the right upper abdomen and severe symptoms may require hospital admission, intravenous antibiotics and in some cases, surgery.

Bile duct stones (choledocholithiasis): This condition occurs when the gallstone slips into the bile duct which carries bile from the liver to the small intestine. This can result in jaundice (yellowing of eyes), abdominal pain and fever, a condition known as cholangitis (infection of bile duct).

Acute biliary pancreatitis: This refers to inflammation of the pancreas, which occurs due to the blockage of the pancreatic duct by gallstone, preventing digestive enzymes from flowing into the small intestine. Symptoms may include severe upper abdominal pain, nausea and vomiting. The symptoms may worsen and the patient may require ICU admission.

Gallbladder cancer: In rare cases, gallstones may lead to gallbladder cancer which is one of the most aggressive cancers of the body.

Indication of Surgery in gallstones               

Surgery is the most common treatment for gallstone disease when symptoms are present. The primary indication for gallbladder surgery (cholecystectomy) is the presence of symptomatic gallstones. Symptomatic gallstones can cause significant pain, inflammation, infection, and other complications. These complications may include acute cholecystitis (inflammation of the gallbladder), cholangitis (infection of the bile duct), and pancreatitis (inflammation of the pancreas).

Other indications for surgery may include the presence of large gallstones, stones in the bile duct, or gallbladder polyps. Patients with a high risk of developing gallbladder cancer may also require surgery, Dr Kamal Kataria says.

Additionally, patients with asymptomatic gallstones may require surgery if they have certain risk factors such as age over 60, Diabetes Mellitus (poor follow-up capacity, poorly controlled, high risk of empyema), Sickle cell disease, TPN, Chronic immunosuppression, or other medical conditions that increase the risk of complications, chips in Dr Gagan Soni.

He cautions that there are some contraindications of surgery in gallstones.

“Meaning, there are some conditions or situations in which surgery is not recommended or is considered unsafe. For instance  in some conditions like unstable medical conditions (uncontrolled high blood pressure, heart disease, or a bleeding disorder), pregnancy especially during the first and third trimesters, advanced age, severe lung or kidney disease, recent surgery or trauma, and other medical complications.

These contraindications may increase the risk of complications during or after surgery and may require alternative treatments to be pursued instead of surgery.

“It is important to note that these are general contraindications, and the decision to undergo surgery should be made on an individual basis after a thorough evaluation of the person's medical history, condition, and other factors. In some cases, alternative treatments such as medication or endoscopic procedures may be recommended instead of surgery,” Dr Kataria further explains.

Difficulties in operation

Dr Chumber says that surgery is a common treatment for gallstones, but it can present some difficulties and risks. The most common surgical procedure for gallstones is called a cholecystectomy, which involves the removal of the gallbladder, either by opening the tummy or through key-hole surgery (laparoscopy).

One of the main difficulties in gallstone surgery is identifying and removing all of the stones. Gallstones can be small and difficult to detect, and some may be located outside of the gallbladder in the bile ducts, making them harder to reach and remove, says Dr Chumber.

Another difficulty is the risk of injury to nearby organs or structures during surgery. The gallbladder is located in a delicate area, close to the liver, bile ducts, and several blood vessels. Surgeons needs to be careful to avoid damaging these structures during the operation.

Additionally, some patients may be at a higher risk of complications during surgery, such as those with pre-existing medical conditions or a history of previous surgery in the tummy.

Overall, while gallstone surgery done via keyhole (laparoscopy) is generally safe and effective, it is important to discuss any potential risks and difficulties with a healthcare provider before undergoing the procedure, adds Dr Mohan.

Symptoms of gallstone disease

Symptoms can vary, depending on the type and severity of the condition, say Dr Sunil Chumber and Dr Ajay Mohan

• Biliary colic is a common symptom of gallstones, and it is characterized by sudden and intense pain in the upper right part of the tummy, which may spread to the shoulder or back. The pain can last for several hours, and it may be triggered by eating fatty foods.
•  Acute cholecystitis occurs when a gallstone blocks the duct that carries the digestive fluid (bile) out of the gallbladder, causing inflammation and swelling of the organ. The symptoms of acute cholecystitis may include severe pain in the upper right part of the tummy, nausea, vomiting, fever, and chills.
•  Chronic cholecystitis is a long-term condition that occurs when the gallbladder becomes inflamed and damaged due to the presence of gallstones. Recurrent episodes of pain in the upper right part of the tummy, nausea, bloating, and indigestion are common symptoms.
• CBD stones, or common bile duct stones, occur when gallstones move out of the gallbladder and into the tube or duct that carries the digestive fluid (bile) from the liver to the small intestine. The symptoms of CBD stones may include pain in the upper right part of the tummy, jaundice (yellowing of the skin and eyes), and fever.

...To be continued